1例立克次体相关性脓毒性休克患者抗感染治疗的药学监护

Pharmaceutical Care of Anti-infective Treatment in a Patient with Rickettsia-associated Septic Shock

目的:分析1例立克次体相关性脓毒性休克患者抗感染治疗的药学监护过程,为临床立克次体所致严重感染的诊断和治疗提供参考。方法与结果:该患者6 d前无明显诱因情况下出现发热和干咳,1 d前又出现呼吸困难,入院检查显示降钙素原(3.23 ng/mL)和C反应蛋白(120.4 mg/L)明显升高,遂临床医生予以亚胺培南-西司他丁钠、左氧氟沙星、利巴韦林经验性抗感染治疗;第2天,患者表现出脓毒性休克症状,临床药师会诊后建议将抗感染治疗方案调整为美罗培南和阿奇霉素;第4日,患者血标本的宏基因组二代测序(metagenomic next-generation sequencing,mNGS)检测结果显示日本立克次体呈阳性,而痰标本的mNGS结果显示肺炎克雷伯菌、缓症链球菌、肺炎链球菌和热带假丝酵母呈阳性,临床药师认为日本立克次体为病原菌,而其他则为定植菌,故建议将抗感染治疗方案改为多西环素,但临床医生出于稳妥起见加用了哌拉西林-他唑巴坦钠;3 d后,患者体温恢复正常,感染指标和相关症状亦明显改善,并在不久后出院。结论:立克次体引起脓毒性休克情况相对较为少见,因而临床相对容易忽视,临床药师在开展药学监护时应综合分析患者的临床表现、检查结果和用药史,协助临床医生尽快确定感染的病原菌,从而有针对性地开展抗感染治疗,以保证患者快速康复。

Objective:To analyze the pharmaceutical care process of anti-infective treatment in a patient with Rickettsia-associated septic shock,and provide reference for the diagnosis and treatment of serious infection caused by Rickettsia in clinical practice.Methods and Results:The patient developed fever and dry cough without obvious inducement 6 days ago,and dyspnea 1 day ago.The examination at admission showed that the procalcitonin(3.23 ng/mL)and C-reactive protein(120.4 mg/L)levels increased obviously,so the clinician gave empiric anti-infective treatment with imipenem-cilastatin sodium,levofloxacin,and ribavirin;on the 2nd day,the patient showed symptoms of septic shock,and after consultation with the clinical pharmacist,it was suggested that the anti-infective treatment regimen was adjust to meropenem and azithromycin;on the 4th day,the metagenomic next-generation sequencing(mNGS)test results of the patient's blood samples showed positive for Rickettsia japonica,while the mNGS results of the sputum samples showed positive for Klebsiella pneumoniae,Streptococcus mitis,Streptococcus pneumoniae and Candida tropicalis.The clinical pharmacists believed that Rickettsia japonicum was pathogenic bacteria and the others were colonized bacteria,so it was suggested that the anti-infective treatment regimen was changed to doxycycline,but the clinician added piperacillin-tazobactam sodium for the safety purpose;3 days later,the patient's body temperature returned to normal,infection indicators and related symptoms were obviously improved,and the patient was discharged from the hospital soon.Conclusion:Septic shock caused by Rickettsia is relatively rare,so it is easily ignored in clinical practice.When carrying out the pharmaceutical care,clinical pharmacists should comprehensively analyze the patient's clinical manifestations,examination results and medication history,assist clinicians in identifying the pathogenic bacteria of infection as quickly as possible,so that the targeted anti-infective treatment is carried out to ensure rapid recovery of the patient.